The pilot/the surgeon is the method

The outcome of a plane flight can be 

a routine landing (not news)

Or this

recent fatal crash of Air India flight (see news)

or this

an Airbus A320 flying from LaGuardia struck a flock of Canada geese shortly after takeoff, resulting in total engine failure. Capt. Chesley “Sully” Sullenberger guided the powerless plane into the Hudson River—fully intact—and all 155 people on board survived (see news)

Learning from adverse outcomes requires consideration of the plane and external factors (e.g. geese). But from the moment the plane takes off, the pilot is the method. 

When we do studies of surgical outcomes, we commonly study patient and implant characteristics, as in the very important study Risk Factors of Acromial and Scapular Spine Stress Fractures Differ by Indication: A Study by the ASES Complications of Reverse Shoulder Arthroplasty Multicenter Research Group, a study that sought to determine patient factors associated with cumulative acromial and scapular spine fractures in 4764 reverse total shoulder arthroplasties performed for patients with diagnoses of arthritis, cuff tear arthropathy and massive rotator cuff tears by 24 surgeon members of the American Shoulder and Elbow Surgeons

Stress fractures were identified in 1 of 50 patients with osteoarthritis and 1 of 20 patients with cuff tear arthropathy or massive rotator cuff tears. In the osteoarthritis group, inflammatory arthritis was associated with an increased risk of fracture. In the cuff tear arthropathy/massive rotator cuff tears group, inflammatory arthritis, female sex, and osteoporosis were associated with increased risk of fracture.

When a plane prepares for takeoff, the pilot is the method. When a surgical procedure begins, the surgeon is the method. In spite of the fact that the surgeon is a major determinant of the outcome, the "surgeon effect" is rarely studied.  

The authors of the study referenced above are in a powerful position to compare outcomes (stress fracture rates, revision rates, patient reported comfort and function) among the 24 surgeons: if indeed there were 4764 cases, the average case volume/surgeon was 200 cases! How variable were the outcomes among surgeons? How much of this variability was due to differences in surgical indication? If surgical indication was an incomplete predictor of the variability among surgeons, what other factors might have been in play? What can we learn from inter-surgeon differences in practice and outcome, i.e. noise?

Hopefully, this study group will consider adding "the surgeon effect" to their research.

After take off, the eagle is the method

Bald Eagle

Leavenworth, WA

April 2025

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

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